Disparities in health insurance coverage must be addressed as an important first step toward eliminating the health care disparities that disproportionately affect the economically disadvantaged and people of color. Examples of such health care disparities include the black infant mortality rate, which at 13.6 infant deaths per 1,000 live births is double that of non-Hispanic whites (NHWs) at 5.7. [1] Another example is diabetes; 13 percent of Hispanics and 15 percent of black adults have diabetes versus 8 percent of NHWs. [2] The causes of these health disparities are complex and multifactorial and include issues related to the environment, poverty, housing, education, health behaviors, and even segregation and discrimination. Another important contributor to these health care disparities is the difference in quality of the health care received by racial or ethnic minorities versus that of NHWs. Examples of these health care disparities include blacks' receiving fewer bypass surgeries and kidney transplants than NHWs. Although blacks are one and a half times more likely to die from heart disease than whites, the rate of bypass surgery among whites was 9 per 1,000 versus 4 per 1,000 among blacks in 2001. [3] Similarly, while over 50 percent of NHWs have received age-appropriate colorectal cancer screening, only 35 percent of Asians and Hispanics have had such tests. [4]

In 1999, Congress commissioned the Institute of Medicine (IOM) to produce an in-depth report on health care disparities. The charge was to examine the existence of disparities that were not due to known factors such as health insurance coverage and ability to pay. What the IOM found was that even after accounting for insurance, members of racial and ethnic minorities received lower-quality health care than NHWs. Yet, as this landmark report points out, disentangling the impact of known causes of disparities, such as access to affordable health insurance, from broader economic and social inequities is an "artificial and difficult distinction." The IOM noted that while disparities in access to affordable quality health care are "likely the most significant barrier to equitable care," other factors such as bias, discrimination, and negative racial stereotypes are also important barriers to equitable care. Additional contributors to health care disparities included cultural and linguistic barriers, lack of a stable primary care clinician, and fragmentation of the health care system.

The annual statistics published by the Census Bureau portray a dismal picture of health insurance coverage among minorities. [5] The data show that one-third of Latinos in the United States lack health insurance coverage and 20 percent of both blacks and Asians in the United States are uninsured as well. In contrast, only 10 percent of NHWs are uninsured. Further, from 1987 to 2005, the proportion of the uninsured population in the United States that is minority has increased from 42 percent to 53 percent. [6] Among Latinos and Asians, the most vulnerable are immigrants. Over half of noncitizen Latinos and nearly a third of noncitizen Asians in the United States lack health coverage. It also estimated that nearly 80 percent of undocumented immigrants lack insurance. However, even U.S.-born Latinos (over 60 percent of all Latinos are U.S. born) are twice as likely as NHWs to lack coverage. Thus, immigration status by itself does not explain a large proportion of the disparities in health coverage between minorities and NHWs in the United States.

Medical Apartheid in the United States

In the absence of a system of universal health care, a multitier health care system has developed in the United States, one that results in what can be described as health care segregation. In the highest tier are those who have private insurance coverage, usually through their employer or Medicare. These insurance programs are widely accepted by physicians and hospitals. At the other end are the uninsured. In theory, they can pay for their health care services out of pocket. In reality, as most of the uninsured are either poor or middle class, they often forgo necessary care. Their alternative is to rely on a safety net patchwork of providers including community health centers, outpatient departments of public and some not-for-profit hospitals, and emergency rooms. While an important source of care for the uninsured, such patched-together systems are a far cry from the care received by privately insured and Medicare populations. In particular, access to subspecialty care and a stable source of outpatient medications are major barriers to care in these safety-net systems. While 85 percent of NHWs in this country belong to the highest tier of health care, only 63 percent of blacks and 50 percent of Hispanics belong to this top tier of access (see Figure 7.1). Further, while racial and ethnic minorities make up less than a third of the U.S. population, over half of all persons in this lowest tier of health care are minorities.

In the middle tier are those covered through the various insurance programs serving the poor such as Medicaid and the State Children's Health Insurance Programs (SCHIP). These programs are critical components of the health care safety net and cover 40 million children and adults. Unfortunately, as is true for most other poverty programs, they suffer chronic underfunding and applicants face onerous eligibility and recertification requirements. In some states, over half of all persons who enroll are disenrolled in under a year. Further, when facing budgetary difficulties, limiting enrollment in these programs or rationing health care services through cutbacks of services covered is a favorite ploy of many legislators. Thus, for many enrollees, such programs are a far cry from the comprehensive, ongoing health care access that persons in the first tier enjoy.

Figure 7.1 Medical Apartheid in the United States

The real reason that these underfunded programs are segregated is that in most states providers are paid at levels much lower than Medicare. As an example, in New York a private physician can be paid six times more to see a patient with Medicare versus Medicaid. As a result, fewer than half of all providers nationally choose to accept Medicaid patients. In many localities, this forces most Medicaid patients to receive care through the same network of safety net clinics that exist for the uninsured. Further, access to subspecialty care in these settings is often as problematic as it is with the uninsured. As an example, in one large hospital in New York City, the wait for a Medicaid patient to see a gastroenterologist is eight months. In contrast, a patient with Medicare could be seen within two weeks in the private offices that are part of the same medical center but do not accept Medicaid patients. The government also reinforces this segregated system of care, because it provides additional subsidies or grants for designated safety net providers and clinics to see Medicaid patients but does not make such funds available to providers in private practice. This segregationist system is quite effective at ensuring that those in the first tier receive a different level of care from those in the second and third tiers. A report by one advocacy coalition, Bronx Reach Coalition, extensively described this system of segregated care and unequal access faced by poor and predominantly minority patients as "Medical Apartheid." [7] Among the report's conclusions were that people who are uninsured or publicly insured (through Medicaid, Medicaid Managed Care, Family Health Plus, and Child Health Plus) are often cared for in separate institutions from those who are privately insured. The coalition also found that even within health care institutions, separate and unequal systems of care exist. The uninsured, people covered by Medicaid, and sometimes even those enrolled in Medicaid Managed Care, Family Health Plus, and Child Health Plus receive poorer care in different locations, at different times, and by less-trained physicians than those who are privately insured. Finally, the report shows that when patients are sorted according to their insurance status, this segregated care leads to different health outcomes.

Can One Size Possibly Fit All?

Other chapters in this book have discussed the limitations of the market-based solutions espoused by most Republicans, whose central premise is that health care is a commodity and should be distributed based on ability to pay. Such market-based initiatives would clearly widen the gap in health and health care between the haves and have-nots in our society. This is not a Republican-versus-Democrat problem, however. Almost as troubling are the Democratic approaches that call for placing most low-income uninsured persons into safety-net health insurance programs such as Medicaid. When pressed on the issue, many Democrats agree that a system that provides equitable, comprehensive coverage would go a long way toward addressing health disparities. Yet they usually then cite vague terms such as "political feasibility" and "compromise" and some not-so-vague terms such as "powerful opposition" to explain why they favor approaches that would institutionalize apartheid and discrimination in health care. In fact, they are willing to champion a racist system of health care rather than stand up to the pharmaceutical and for-profit health insurance industries.

In contrast, under a comprehensive national health insurance plan, a wealthy NHW male would have the same level of coverage as a low-income black female. Detractors claim that this one-size-fits-all approach is not consistent with American values and that individuals should have the freedom to choose the level and quality of health care they wish to receive. However, such detractors have a hard time identifying persons who would want to receive low-quality health care. Clearly, under the mantra of choice, it would be minorities who would disproportionately be stuck in the lowest levels of health care. From a perspective of basic fairness, it is clear that having one system of care in which access to high-quality health care would be a right of all is far superior to one in which quality of coverage is determined by income.

Does Everyone in and No One out Include All Immigrants?

Immigrants contribute tens of billions of dollars to our economy, and the sustainability of programs such as Social Security and Medicare to a significant extent depends on taxes paid by such workers. Further, health costs for immigrants are about one-third those of NHWs. Ethical, religious, and humane issues could all be raised to support improving access to care for such immigrants. However, the main reason all immigrants would be included in national health insurance (NHI) is financial. Not only are immigrants relatively inexpensive to cover, but to exclude them would mean maintenance of very expensive administrative systems of billing and indirect and inefficient safety-net reimbursement mechanisms. Simply put, NHI would be much more costly if a system needs to be maintained to exclude 12 million undocumented persons. Thus, comprehensive coverage of all residents of the United States would be far more humane and less costly.

Political and Organizational Support for NHI among Minorities

Since NHI is the only proposal for universal coverage that would ensure equitable high- quality health care for all, it has long been supported by the Congressional Black Caucus. Over half the members of the Congressional Hispanic Caucus also support HR 676. NHI also enjoys support among large minority medical groups such as the National Medical Association and the National Hispanic Medical Association. In response, the strategy favored by the insurance and pharmaceutical industries has been to partner with minority political leaders and organizations on other important disparities issues such as workforce diversity, cultural competency, and language barriers -- but not on NHI. By lavishing groups with funding for other initiatives, these opponents of single-payer hope not only to gain the goodwill of these political leaders and organizations but also to divert advocacy on behalf of NHI. Fortunately, so far this approach has had limited success, with the majority of minority leaders and organizations remaining strong advocates of NHI.

Will NHI end disparities? No. Health disparities are an extremely complex and multifaceted problem that has long plagued our society. As we've said earlier, disparities in health are due to a variety of factors -- including environment, housing, poverty, education, and racism -- that go far beyond just having insurance. Indeed, even in countries that have universal coverage, the wealthy and privileged enjoy better health status and find ways to receive better access to care than those in poverty. However, the magnitude of health care disparities in those countries is significantly less than in the United States. Many of us believe that once we have enacted a system of equitable, comprehensive coverage for all, we can then focus on addressing other important issues. These include ensuring a health care workforce whose diversity is reflective of our society, health care providers who are culturally and linguistically competent to provide care to persons from a wide variety of racial and ethnic backgrounds, and a health care delivery system that is free of the many racial and ethnic biases and stereotypes that plague our society. But since disparities in access to quality health care are a major contributor to disparities in health, health insurance is the key driver of many health care disparities, and efforts to address disparities must start with the most glaring and obvious factor.

_______________

Note:

Olveen Carrasquillo, MD, MPH, is an Associate Professor of Medicine, Health Policy and Community Partnerships at Columbia University Medical Center. Jaime Torres, DPM, MS, is the founder and president of Latinos for National Health Insurance.

Health care is one of the top domestic issues for Americans. The cost of health care continues to rise sharply, out-pacing overall inflation and wage growth and adding pressure to already stretched family budgets. Health spending now accounts for 16 percent of our nation's gross domestic product, up from 13.8 percent in 2000. [1] Over the past six years, health insurance premiums have increased by more than six times the median income (73.8 percent versus 11.6 percent). [2]As low- and middle-income Americans try to secure health care for their families, these spiraling costs are landing many households in the red.

The number of Americans without health insurance coverage grew by more than 2 million between 2005 and 2006, with 47 million Americans -- just under 16 percent of the population -- having no coverage. [3] The vast majority of Americans with health insurance have coverage through their own or a family member's workplace. [4] However, as employers look to rein in benefit costs, workers are experiencing a decrease in the value of the insurance. Employers are selecting insurance policies that require greater employee cost sharing through higher deductibles, copayments, and other forms of out-of-pocket expenses. [5] Some employers are eliminating coverage altogether. Sixty percent of American businesses offered coverage to their employees in 2007, a dramatic drop from 69 percent in the year 2000. [6]

As the 2008 presidential candidates propose solutions to address the lack of health insurance for 47 million Americans. attention must be paid to the quality of health insurance coverage offered them. Many insured Americans are feeling financially burdened by health care costs. It is estimated that more than 45 million Americans live in households where more than 10 percent of after-tax family income is being spent on insurance premiums and out-of-pocket health care expenses. [7]

It is well established that uninsured Americans do not have equal access to health care. They are also particularly vulnerable to medical bill problems and to medical debt. [8] Unfortunately, such struggles are far from limited to the uninsured. A recent national survey found that a quarter of Americans have medical bills or medical debts that they are paying off over time and among this group over two-thirds have health insurance. [9] Numerous studies have found that large numbers of both insured and uninsured Americans have difficulty paying medical bills and are even falling into debt. [10]

Number of Uninsured Americans 1976-2006

Simply stated, medical debt is a growing problem with severe consequences for both access to necessary health care services and financial stability. Studies have documented that adults with medical debt, whether insured or uninsured, are more likely than those without debt to skip recommended treatments, leave drug prescriptions unfilled, and postpone care because of cost. [11] Roughly half of all personal bankruptcies are due in part to medical problems. [12] Even relatively small levels of medical debt can have major consequences on financial security. [13]

To meet out-of-pocket medical expenses, many patients are turning to credit in order to avoid owing money directly to the providers of their care. Late in 2007, investigative journalists uncovered lending practices that were considered predatory by some experts. Practices uncovered included offers too good to be true such as zero percent interest health credit cards. Many patients saw their interest rate skyrocket to more than 25 percent with one late payment. Some patients were charged excessive fees for the services they received, and the interest on those fees resulted in patients' struggling to make the minimum monthly payment; still others were dunned by collection agencies using aggressive tactics to extract payment from people without available cash to pay their unexpected medical bills. The documentation of such tactics prompted Senator Charles Grassley (R-Iowa), ranking member of the Senate Finance Committee, to state, "I'm very troubled by what we're seeing with some nonprofit hospitals' cozying up to banks, debt buyers, and credit-card companies over patients' medical bills." [14]

Using a credit card for medical expenses is especially pernicious because it subjects patients to high interest rates, harsh late fees, and penalties. To gain a better understanding of this phenomenon, Demos and The Access Project partnered to analyze data from Demos's national household survey of low- and moderate-income households with credit card debt. Included in this survey were questions about medical expenses as a component of credit card debt and health insurance status. The results, which we reproduce in summary form in the remainder of this chapter, were published in a 2006 report jointly released by Demos and The Access Project entitled "Borrowing to Stay Healthy." [15]

Most of the Medically Bankrupt Had Coverage

Our findings show that low- and middle-income households who cited medical expenses as a factor in their credit card debt had higher levels of credit card debt than those who did not cite this factor. Overall in the survey, nearly one in three (29 percent) of low- and middle-income households with credit card debt reported that medical expenses contributed to their current level of credit card debt. Within that group, the vast majority (69 percent) had a major medical expense in the previous three years. Overall, one in five (20 percent) of indebted low- and middle-income households reported having a major medical expense in the previous three years and that medical expenses contributed to their current level of credit card debt. Within this "medically indebted" group, we found that over half (57 percent) had credit card debt higher than $5,000, with the vast majority of them having credit card debt higher than $10,000. Average credit card debt was also far higher for low- and middle-income medically indebted households as compared to households who neither had a recent major medical expense nor cited medical expenses as contributing to their credit card debt. For households with medical debt on their credit cards, average credit card debt was higher for those without health insurance. Medical debt can seriously threaten both financial well-being and access to health care services. The low- to middle-income households in our survey showed many signs of financial stress; a majority of them cited having been called by bill collectors, and one in seven (15 percent) had declared bankruptcy.

Our report also discussed the rise of medical credit cards and loans and how these products fit into the picture for patients with medical debt. To help place these lending products into context, let us first discuss the many health insurance gaps that created the opening for them. In part to stem the growth of health insurance premiums, more insurers and employers are offering insurance plans that feature higher levels of cost sharing, potentially exposing low- and moderate-income patients to financial stress.

Holes in health insurance plans include medications, procedures, and medical equipment excluded from coverage, higher rates of cost sharing for out-of-network providers, and multiple deductibles. [16] More than a fifth of workers are in insurance plans without an out-of-pocket maximum and about half of workers are in health insurance plans with a lifetime benefit maximum. [17] When illness strikes, these gaps often result in crushing medical debt. Of course, the 47 million Americans without any health insurance face the greatest risk. Despite the common perception that the uninsured receive free care in the emergency room setting, there is considerable evidence not only that the uninsured face negative health consequences as a result of being uninsured [18] but also that many patients without health insurance are still billed for services; in fact, because they don't receive the same discounts that insurers negotiate for their members, the uninsured are often billed the full "sticker price" for health care services, landing them in debt to health providers or to the creditors to whom their debt is turned over.

It is estimated that in 2007 Americans spent $265 billion on out-of-pocket health care costs; this is in addition to what they spent on health insurance premiums. This is a tempting amount for creditors who view these costs as a new market niche. A Business Week investigation in late 2007 documented an array of credit cards and lending products that have emerged in recent years to capitalize on out-of-pocket medical expenses that exceed patients' ability to pay. In some cases, medical providers were signing up patients unable to pay their medical bills for a medical credit card without their full understanding of the credit terms, leaving these patients with large bills quickly accruing interest.

Many medical providers are looking for new ways to manage their accounts receivable. Partnering with fiscal intermediaries, facilitating connections with lenders, and contracting with collection agencies are becoming quite common. Increasingly, medical providers are looking to sell their accounts to debt buyers who are quite interested in this market, especially given its size. [19] Unfortunately for consumers, such transactions can result in serious consequences as unaffordable medical bills are transformed into delinquent accounts and reported to the credit bureaus.

Policymakers must address the twin problems of rising health care costs and eroding coverage in a comprehensive manner to protect American families from the financial insecurity and deleterious health outcomes that can result from medical debt. Policymakers should pursue an approach that provides universal, affordable access to comprehensive benefits without exposing patients and their families to the burden of medical debt.

_______________

Note:

Cindy Zeldin is a health policy researcher with nearly a decade of public policy experience at the state and national levels. Mark Rukavina is the Executive Director of the Access Project.

Today the nation is faced with a private/public health care financing system that has left one-third of the American people with either inadequate health insurance or no coverage at all. Forty-nine percent of people with insurance tell pollsters they are somewhat or completely unprepared to cope with a costly medical emergency over the coming year. [1] Twenty-nine percent of people with underinsurance often postpone medical care because of costs, problems compounded by the fact that incomes have been relatively stagnant for active workers and are in decline for those on fixed incomes. [2] Premiums are going up while benefits are going down. Four percent of middle-income families -- those earning between $40,000 and $80,000 annually -- lost employer-based health insurance between 2000 and 2005. [3] Four percent may sound small, but it represents 2 million families. [4] Half of those families lost their insurance because their employers abandoned health insurance programs; another 15 percent lost their insurance because their premiums became unaffordable.

Union negotiators and health care program administrators have spent years pulling rabbits out of hats to compensate for the increasing costs of health care. Introducing generic drugs and preferred provider organizations and raising deductibles and co-pays have all been strategies developed to patch a collapsing system. Despite these "innovations," employers' costs of group health insurance went from $331 billion in 2000 to $514 billion in 2005, or about 9 percent of total wage and salary costs. [5]

Many of today's collective bargaining disputes are driven by health care costs.

Rather than joining labor to lobby for universal, affordable health care, private employers are abandoning financial responsibility for health care costs at the rate of about 5 percent per year, reducing the number of group plan participants, driving down employee living standards, and further undermining private-sector health care financing. [6] As employer definancing of health care continues unabated, the move to a national system will no longer be a choice; it will be a necessity in order to maintain any health care system whatsoever.

Undermining Global Competitiveness

Employers increasingly point to the disadvantage they suffer when competing globally, especially companies operating in the many nations that have developed uniform, government-supported health care. In those nations, even where financing is derived from both private and public sources, administration of the system and guidelines for care have become publicly supported social services.

In the United States, where financial accounting standards require employers to carry their long-term liabilities for retiree health care on their balance sheets, unions are put in the unenviable but inevitable position of having to press demands for health care benefit coverage in bargaining not only for their existing dues-paying members but also for a considerable number of retirees. Especially in the industrial sectors of the economy, the number of retirees whose interests must be represented often far exceeds the number of active members, as was the case with United Steelworkers (USW) negotiations with the Goodyear Tire and Rubber Company and more recently in the United Automobile Workers' negotiations with the auto industry.

It is little wonder, then, that in negotiations with these companies, unions have felt compelled by the twin goals of preserving and securing retiree benefits and keeping employers competitive to negotiate Voluntary Employee Benefits Associations (VEBAs), trusts funded by the companies and administered by boards of trustees independent of the employer. Because their assets will be immune from any potential bankruptcy of the employer, these VEBAs provide continuing and secured health care benefits for current and future retirees while lifting a significant body of health care liabilities that employers are obliged to carry on their books. And their assets can be increased through contributions negotiated in future contract bargaining. No competitor of General Motors or Goodyear elsewhere in the industrialized world carries such liabilities or obligations, as all are beneficiaries of health care subsidized by their governments in one fashion or another. Only in the United States must these obligations be secured through collective bargaining if workers and retirees are to have any hope of receiving health care benefits. (The value of securing such benefits is of course not lost on those workers who have enjoyed health care coverage only to see it wiped out by their employers' bankruptcies.)

Cruel Irony

That retired union members should be among those most victimized by the nation's health care crisis is cruelly ironic, for the origins of America's current health care financing system are rooted in labor-management collective bargaining agreements forged during World War II. Negotiators introduced enhanced health care benefits as a reward for workers during a period when wage increases were restricted by war policy measures. These benefits soon became a standard part of employment compensation.

The result was a stable financial base for the growth and improvement of health care systems across the nation. Communities had money for hospitals and infrastructure. The medical profession was able to upgrade its capabilities, do more research, and professionalize care. Financing was handled by a growing private insurance industry that was dominated by nonprofit-style carriers. But there was another, less noticed outcome of America's health care evolution. Health care professionals began to enjoy a new upper- middle-class status, and health insurance executives became increasingly acquisitive as they gained control of significant pools of health insurance reserves. Eventually a system that had been nonprofit in character morphed into a for-profit enterprise, with costs spiraling out of control as the health insurance industry became concerned with the bottom line rather than providing a real health care benefit to working Americans.

The Private System's Shortcomings

Rife with inefficiency and shaped by the drive for profit and exorbitant executive compensation, the private financing system is inherently ill-equipped to provide equitable health care for all of America's population, let alone to continue to provide it affordably to workers with a union contract. As the costs of care have increased, often much more rapidly than the rate of inflation, the deficiencies of a system that relies disproportionately on employer-based financing have become more apparent.

The inefficiency and rising costs of the American health care system have ripple effects throughout the economy, affecting not only unions but all Americans. Health care costs impede efforts to reverse the United States' massive trade deficits, which are further eroding competitiveness and well-paying jobs. Our product and service costs are driven up by the refusal to implement an efficient health care system. Some estimates cite the waste in our health care system as representing as much as 7 percent of the nation's productive capacity (gross domestic product). [7] Since we are a debtor nation, these costs flow directly into the national debt and further weaken our national financial strength.

Corporate Blind Mice

The best face that can be put on the unwillingness of corporate executives to abandon our broken system in favor of universal health care is their misbegotten belief that the current system can be stabilized enough to make the costs amenable to effective business planning. Yet, in reality, as things stand today, businesses have no leverage whatsoever over either quality or price. Their only "control" is over the amount of coverage they will pay for -- an approach they all too frequently default to in contract negotiations.

A national single-payer system would relieve corporations of the burden of health insurance administration, stabilize costs, and give corporations the global level playing field they want. Businesses can play a major role in solving the health care dilemma, therefore, by overcoming their blind resistance to a national system and insisting instead that a national plan be designed that provides their employees with proper coverage without runaway costs. Universal coverage through a single-payer system offers the best hope of achieving these goals.

It's so simple. Most people who can't afford health insurance are also too poor to owe taxes. But if you give them a deduction from the taxes they don't owe, they can use the money they're not getting back to buy the health care they can't afford.

10. It's what most Americans want -- and we can make it happenby Joanne Landy and Oliver Fein

The irony about the debate over national health insurance in the United States is that we have excellent hospitals, skilled practitioners, and the technological infrastructure -- and we're already spending enough money to insure everyone and to improve access to care for many who are covered today by inadequate plans. All we need is the political will.

Although the barriers to single-payer reform are considerable, we ignore them at our peril. Private, for-profit insurance companies will of course fight tooth and nail against any system that will remove them from a significant role in the country's health care. Big Pharma too will use its clout to try to defeat single payer; the drug companies want multiple fragmented private purchasers rather than a single public payer with the power to negotiate lower prices for everyone. Moreover, most politicians are, right now, of little help. Too often they take money from and are then beholden to insurance and drug companies. (However, with sufficient popular pressure, many politicians would have to change their stance and could add important strength and credibility to the fight for single payer.) In addition, numerous economists and health care "experts" lend legitimacy to the current system by advocating market-oriented reforms, reforms that fail to be truly universal, and meanwhile pour more money into private insurance companies. Finally, while employers often complain about the high cost of private health insurance premiums, they have thus far chosen to deal with rising premiums by shifting costs to their employees rather than by supporting a public insurance solution.

Overcoming these obstacles will require an informed public that demands meaningful change. The movement for single payer has made great strides, drawing on the fact that most people in this country have come to distrust insurance companies. But many Americans have grown increasingly distrustful of government in recent years. It is not uncommon to hear comments like "You mean you want the government that didn't rescue New Orleans after Katrina to solve the health care crisis? Forget it!" Understandably, those with health insurance fear that they will lose the benefits they have now and that the cost of a government-financed system will mean that they will have to pay extraordinarily high taxes and will end up even worse off than they are now.

However, as the chapters in this book illustrate, the arguments against single payer don't measure up to the evidence. Here are some of the myths that need to be dispelled:

• Universal coverage costs too much. No, it doesn't. Every other industrialized nation offers its people universal coverage, and at a cost much lower than we now spend in the United States, which covers only part of its population. In 2005, we spent 15.3 percent of our gross domestic product on health care compared to France's 11.1 percent, Germany's 10.7 percent, and Canada's 9.8 per cent. [1] Yet, in 2005 we had 45 million uninsured (it's 2 million more at this writing!) while other industrialiazed countries covered everyone's health care.

• Your taxes will go up. Perhaps, but you are still likely to come out ahead when you consider the overall expenses. Single payer will cost most people the same or less than the premiums and medical bills they are paying today and will be secure regardless of employment or income. Both the Congressional Budget Office and the General Accounting Office have testified that the United States could insure everyone for the amount of money we're spending. [2]

• Americans get world-class care -- we shouldn't mess around with that. The fact is that many Americans don't get world-class care. Sure, if you are wealthy and have the best private insurance, your chances of gelling excellent care are high. But on almost all measures of health care and mortality, we lag behind Canada and Europe. [3]

• Other countries have much longer waiting times than we do. In actuality in other industrialized countries there are no waiting lists for emergency surgery or urgently needed procedures. It's true that the United States has shorter waits for elective surgery than Canada and England. But recent studies show that some waiting times in the United States are longer than in other countries. For example, in a study of seven developed countries, the Commonwealth Fund looked at how many sick adults had to wait six days or more for an appointment. [4] By this measure, only Canada's record was worse than ours. Within our market-driven system, an appointment for cosmetic surgery may be scheduled sooner than an appointment for possible skin cancer. A recent study reported an average wait of seventy-three days for patients with possible skin cancer in Boston. [5]

• There is no problem; people get care even if they're uninsured. Don't tell that to the American Cancer Society (ACS), which in September 2007 worked with its sister advocacy organization, the ACS Cancer Action Network, to launch a major initiative to make access to health care a state and national priority. Research shows that uninsured patients were much more likely to have their cancers diagnosed at an advanced stage, when they are less curable, than were patients with insurance. [6] John Seffrin, the society's chief executive, has stated that unless the health care system is fixed "lack of access will be a bigger cancer killer than tobacco." [7] Of course the problem isn't limited to cancer: the Institute of Medicine estimates that there are 22,000 deaths per year due to lack of insurance. [8] Unnecessary suffering and disease affect millions more who have no insurance or are underinsured.

• Single payer is socialized medicine. Single payer is not socialized medicine, because for the most part government will not own the hospitals and physicians will not be on salary to government. Single payer simply changes the financing of health care; the health care delivery system remains the same. It will operate like the Medicare program for the elderly today, in which patients are seen by private doctors in (mostly) private hospitals; this clearly isn't socialized medicine. Single payer is actually "social insurance" rather than "private insurance."

Everyone -- including most Democrats and some Republicans -- is talking about the need for universal health care coverage and cost controls. Although not everyone endorses single payer at this time, more and more people have jobs with no insurance, and those with insurance are seeing their employers reduce their benefits and increase their contributions for premiums, year by year. The latest General Motors-United Automobile Workers agreement points toward a grim future in which employers try to shed all responsibility for insuring their employees. Meanwhile, every study that compares single payer with tax deductions or tax subsidies to buy private health insurance shows that single payer costs less and guarantees better coverage to more people than all the other approaches.

The evidence supports single payer, and increasing numbers of people in this country are seeing that we don't have to be stuck with the irrational, expensive, and cruel system we have. Michael Moore's SiCKO! has made an incalculable contribution to overcoming ignorance about what is possible: Moore has shown us that by cutting the wasteful and totally unnecessary private insurance industry out of our health care system we can have real universal health insurance. Of course there have been vicious attacks on Moore, but the strong positive response to SiCKO -- from Oprah to the New York Times to Jon Stewart -- has begun to puncture the traditional U.S. media blackout of the truth about single payer. Perhaps most important, Moore has made a convincing case that government can work for people and has brought outrage and a passion for justice to the fight for a humane health care system in the United States. He is among those helping to ignite the movement needed to make it a reality.

In another hopeful sign, more and more groups are endorsing HR 676. This is the bill in the U.S. House of Representatives introduced by Michigan's John Conyers Jr., called the United States National Health Insurance Act or Expanded and Improved Medicare for All. As of this writing HR 676 has been endorsed by the National Organization for Women, the NAACP, and a wide variety of religious and civil groups, including We Be Illin', a group of young people reaching out to their peers to show why they urgently need single payer. HR676 has also been endorsed by 401 union organizations in 48 states including 104 Central Labor Councils and Area Labor Federations and 33 state AFL-CIOs (as of April 23, 2008). The AFL-CIO has adopted a policy statement favoring a Medicare-for-All approach. The Alliance of Retired Americans, but not to date the American Association of Retired Persons (AARP), reaffirmed its earlier support for HR 676 in September 2007. It is encouraging that all these groups have indicated their support for HR 676; the next challenge is gaining endorsement from more organizations and enlisting those that have already endorsed to deploy their resources in an active fight to pass the bill and actually bring single payer to fruition.

More and more physicians are coming around to support a single-payer system. Physicians for a National Health Program (www.PNHP.org) has long advocated single-payer national health insurance, and more doctors are coming to agree with them. In a well-designed study of Massachusetts physicians drawn from the American Medical Association (AMA) master file, 62 percent supported single-payer reform. [9] In January 2008, the American College of Physicians, the second largest physician organization in the United States after the AMA, published a position paper recommending "Single-payer financing models, in which one government entity is the sole third-party payer of health care costs," as one pathway to reform. [10] Recently, the New York State Academy of Family Physicians gave testimony strongly endorsing single payer. The AMA does not have the stranglehold on physician opinion that it once had. Its membership has fallen to 27 percent of physicians. The AMA no longer represents the majority of practicing physicians in the United States. Many physicians are furious with the second-guessing and interference by the private insurance industry, which denies claims and delays treatment and payment. Physicians become frustrated and patients suffer when each private insurance company's pharmaceutical formulary is different, so that patients can't get certain medications or have higher co-pays. Private insurance company rules on prior approvals result in delay or denial of patient care. Physicians feel ethically compromised. The physician is ultimately accountable to the patient, whereas the insurance company has a responsibility only to its stockholders to maximize profits.

The majority of the public favor national health insurance. A full 68 percent said in the September 2006 ABC/Kaiser/USA Today poll that "providing health care coverage for all Americans" was more important than "holding down taxes." [11] The more recent CNN/Opinion Research Corporation poll (May 2007) finds similar results. Asked whether the "government should provide a national health insurance program for all Americans even if this would require higher taxes," 64 percent of the sample said yes, while just 35 percent said no. When CNN asked that same question in January 1995, 55 percent answered yes and 37 percent said no. This is not an explicit endorsement of single payer, of course. It does suggest, though, that more than a majority of Americans see government and higher taxes as part of the solution to the health care crisis -- even when they have not been informed that lower premiums, deductibles, and co-pays would compensate most people for their higher taxes under a single-payer system.

Halfway solutions won't work, particularly those that put more taxpayer money into helping people buy more private health insurance. Private health insurance is not only extremely costly; it will also result in more and more under-insurance and will actually move us away from achieving quality universal coverage. In order to maintain profits and control their costs, private insurers will jack up deductibles and co-pays and cut benefits. Private insurers will do all they can to recruit the healthy and avoid the sick, who are burdened with pre-existing conditions.

That's the fallacy of the "level the playing field" argument put forward by politicians and pundits who propose that we offer Medicare to everyone and let it compete with private health insurance. The competition will not be fair, because private insurers will figure out how to attract the well by offering perks like free health-club memberships and by advertising aggressively among healthier groups, and how to skip over the less healthy by undermarketing to high-risk populations, even if they are legally required to insure all applicants. This will inevitably leave a disproportionate number of the sick to Medicare, which will in turn raise Medicare premiums, which will make it less attractive to healthy people than private insurance.

Many reformers advocate regulating private insurance to prevent these abuses, but the record of government regulation in this country is poor. The private industry being regulated uses its clout to constrain and distort government intervention. Moreover, no one has proposed comprehensive regulations to curb the worst features of the insurance industry, its built-in desire to avoid paying claims. Most regulation being proposed primarily involves selling insurance, not actually paying for health care.

We already have a clear example of how private health insurance avoids regulation when it coexists with public health insurance when we compare traditional Medicare to Medicare Advantage in which private insurance companies provide coverage. These private plans receive 12 to 18 percent more funding than traditional Medicare and yet have been fraught with major problems. "Tens of thousands of Medicare recipients have been victims of deceptive sales tactics and had claims improperly denied by private insurers according to a review of 91 audit reports conducted by the New York Times." [12] The companies reviewed included three of the largest participants in the Medicare market, United Health, Humana, and Wellpoint. The problems, described in the audit reports, include "the improper termination of coverage for people with H.I.V. and AIDS, huge backlogs of claims and complaints, and a failure to answer telephone calls from consumers, doctors and drugstores.... The audits document widespread violations of patients' rights and consumer protection standards. Some violations could directly affect the health of patients -- for example, by delaying access to urgently needed medications."

The danger of halfway solutions is not only that they won't work but also that their failure can discredit the whole effort on behalf of universal coverage. The public will blame the advocates for universal coverage for the lack of improvement in affordability and coverage. Moreover, the halfway measures that have been proposed add legitimacy and resources to the private insurance companies, who will use those assets to fight single payer every step of the way.

The movement for single-payer National Health Insurance in the United States must come from the bottom up, and by the power of our numbers must bring enough politicians over to our side. It won't be easy, given the array of forces that will oppose it. But political outcomes are never determined only by the wishes of powerful elites. And some of the elites (e.g., businesses outside the health insurance and pharmaceutical industries) could potentially be moved by a determined popular movement and by the unwillingness of their employees to accept the growing restrictions and cutbacks on coverage that are generally the preferred response of business.

Building a powerful movement will require a creative combination of activism and education about how the public can start to make their government respond to the needs of ordinary people. It will be a challenge, but the only alternative to a single-payer system is to consign the people of our country to a more and more brutal health care system. The single-payer movement not only can win a humane health care system but also can contribute, in the words of Michael Moore, to making the United States more of a "we" society than a "me" society, one in which the individual and the society can truly flourish.

Health care is an essential safeguard of human life and dignity, and there is an obligation for society to ensure that every person be able to realize this right.

-- Joseph Cardinal Bernardin

If access to health care is considered a human right, who is considered human enough to have that right?

-- Paul Farmer

_______________

Note:

Joanne Landy, MPH, MA, is the former executive director of the New York Metro Chapter of Physicians for a National Health Program. Oliver Fein, MD, is a practicing general internist, Professor of Clinical Medicine and Public Health, and Associate Dean at the Weill Cornell Medical College.

It sometimes seems to me there are two ways of looking at the world. Either you believe we are all in this together and we need to care for one another or you feel that life is nasty, brutish, and short and you can rely only on yourself, your family, and those like you.

In a moral society, we are all in this together. In a moral society, everyone has a right to health care. The tragedy -- and the promise -- of America at the turn of the twenty-first century is that both ways of looking at the world have strong proponents. Fifty years ago, despite Congress's failure to legislate national health care, there were understandings of moral behavior to one another that were largely shared by the broad American public. Hence the subsequent advances in civil rights and the rights of women.

In the interim, powerful ideological forces have not only captured significant arenas of national leadership, but through their control of the corporate world have also promoted an ideology characterized by few rights and their corresponding social responsibilities. Whether one names this ideology neoconservatism or social Darwinism, at its heart it is alien to American ideals, because in its admiration for the individual who with little assistance from others achieves material success, it looks on the person in need -- whether through poverty, misfortune, or disease -- as being intrinsically undeserving.

In a moral America, health care would be a right. In a moral America, we are all in this together. A government-managed single-payer financing system is the only credible means by which the entire population can have equitable health care.

The idea that we're all in this together is not new to America and it is not new to the world. In the wake of the horror of World War II, many countries of the world decided that we needed to stand together and protect and care for one another. The Universal Declaration of Human Rights, adopted by the United Nations in 1948, declares, in part, "Everyone has the right to a standard of living adequate for the health and well-being of himself and his (sic) family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."

The failure of the health care system in today's America to meet the universal ideals intrinsic to human rights and religious morality extends beyond the injustice of unequal access and taints even the nature of the care that is delivered. The provision of health care in America has been subverted from a calling to a commodity measured in patient encounters, tests performed, medications dispensed, beds filled, and above all, to profits distributed to the CEOs and stockholders of hospital corporations, pharmaceutical giants, and health insurance conglomerates. In the process, quality of care suffers as the primary consideration is often cost, not care.

The physician-patient relationship has been perverted, transformed from a caring relationship into a series of billable events. The physician-patient relationship is thereby compromised not only by the physician's motivation to sell the greatest number of services, but also by the motivation of insurance companies to pay for as few such services as possible. It has been estimated that today's physician spends about one third of his or her time satisfying insurance company regulations and seeking approvals for treatment, time the physician could be spending with patients. Managed care companies, HMOs, PPOs, and the like interfere with the physician's ability to develop comprehensive treatment plans for his or her patients.

High premiums force people to choose between health insurance and sustenance, housing, or other needs of a family, making even basic health insurance too expensive for an average individual or family. More than half of all personal bankruptcies are now the result of illness. Even individuals with ostensibly good insurance, let alone those who are uninsured, find themselves in situations where they must sell or spend all assets, including homes, in order to qualify for Medicaid and restore any medical coverage at all.

Several years ago, I was in Norway for a conference. One evening, I walked back to the hotel with a Norwegian. He said to me, "If you slip and fall and break your head open, our nation will care for you as we do for our own people. But if it were to happen to you or me in your own country, we would have to prove we have private health insurance just in order to receive medical assistance. Tell me, what is wrong with you people?"

What is wrong is that we are failing the test of social responsibility. There is something wrong with a society that has the means to provide health care for its entire people but refuses to do so. Dr. Martin Luther King Jr. warned, "A nation that continues year after year to spend more money on military defense than on programs of social uplift is approaching spiritual doom." These many years later, tens of millions of Americans do not have health care coverage.

The great religions of the world affirm that all people are connected to one another, that nature must be sustained and cared for, and that the conditions for a good life must be provided by society. Those in power in the United States, however, promote an "ownership society" that thinly veils the notion that all rights belong to the well-off and none belong to those who find they have nothing.

Civil and human rights have never come without a struggle. In most developed countries, the struggle for health care coverage has been won. Health care is recognized as a societal responsibility. The fight continues in the United States because of the power of greed. However, the insurance companies have overreached, their greed results in misery and suffering and causes millions of Americans to suffer terribly, and thousands to die prematurely.

A single-payer health care system will entitle all persons within the borders of the United States to the provision of health care services, the cost of such services to be equally shared by taxpayers and the government and distributed to providers in a coordinated, comprehensive, and equitable manner.

We really are all in this together.

_______________

Note:

James Winkler is the General Secretary of the General Board of Church and Society.

5. Ibid., and Commonwealth Fund, National Scorecard on US Health System Performance (New York, 2006).

6. Robert J. Blendon et al., "The Public Versus the World Health Organization on Health System Performance," Health Affairs 20 (2001): 3.

7. It is often claimed that Switzerland and, since 2006, the Netherlands rely on private insurance companies, as we do. It is true that these countries use private, including for- profit and nonprofit, insurance companies, but they operate under the most stringent government regulation. They must all offer the same standard benefit package, their premiums are regulated, and individuals pay according to their income, with government subsidy covering the rest. The government performs risk adjustment among the insurers, so there is no incentive for them to select only the healthiest persons and, in Switzerland, they are not permitted to earn a profit on the basic package of benefits.

8. John Holahan, The Cost of Care for the Uninsured (Washington, DC: Urban Institute, November 2005).

9. At $4,500 per person for the 47 million uninsured, private insurance would cost $212 billion. However, there would be less uncompensated care, and the Urban Institute study (ibid.) extrapolated to this year suggests that eliminating this and other costs paid for the uninsured would save about $60 billion.

17. The VA Hospital system should not be confused with hospitals operated by the U.S. Army such as the Walter Reed Army Medical Center, which has been the subject of recent negative press coverage because of substandard care for returning troops.

3. For an elaboration of some of the main arguments in this chapter, see Marie Gottschalk, "Back to the Future? Health Benefits, Organized Labor, and Universal Health Care," journal of Health Politics, Policy and Law 32, no. 5 (December 2007): 923-70.

4. For more details on organized labor and the battle over the Clinton plan and on the development of private-sector health benefits, see Marie Gottschalk, The Shadow Welfare State: Labor, Business and the Politics of Health Care in the United States (Ithaca: Cornell University Press. 2000).

5. Comments made at "A Brookings Institution-New American Foundation Forum: Employment-Based Health Insurance: A Prominent Past. But Does It Have a Future?" Washington, DC, June 16, 2006, http://www.brookings.edu/comm/events/ 20060616.htm (accessed July 18, 2006), p. 15.

21. Henry J. Aaron, "The Cost of Health Care Administration in the United States and Canada-Questionable Answers to a Questionable Question," New England Journal of Medicine 349, no. 8 (August 21, 2003): 801.

24. David U. Himmelstein, Steffie Woolhandler, and Sidney M. Wolfe, "Administrative Waste in the U.S. Health Care System in 2003: The Cost to the Nation, the States, and the District of Columbia. with State-Specific Estimates of Potential Savings," International Journal of Health Services 34. no. 1 (2004): 79-86.

25. Calculated from Himmelstein et al., p. 79.

26. John R. Commons, Institutional Economics: Its Place in Political Economy, vol. 2 (Madison: University of Wisconsin. 1961 [1934]).

27. Comments made at "A Brookings Institution -- New America Foundation Forum," p. 15. The S.E.I.U.'s Web site also proclaims, "It's Time for an American Solution to Our Health Care Crisis." See http://www.S.E.I.U..org/issues/american_solution.cfm (accessed August 9, 2006); and Alonso-Zaldivar, "Q & A."

28. See, for example, Robin Toner and Janet Elder, "Most Support U.S. Guarantee of Health Care," New York Times, March 2, 2007, p. A-1.

5. C. DeNavas.Walt, B.D. Proctor, and C.H. Lee, U.S. Bureau of the Census, Current Population Reports, P60-231, "Income, Poverty, and Health Insurance Coverage in the United States: 2005" (Washington, DC: U.S. Government Printing Office, 2006).

3. U.S. Department of Commerce, Bureau of the Census, "Income, Poverty, and Health Insurance Coverage in the United States: 2006," August 2007.

4. Paul Fronstin, "Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2006 Current Population Survey," Issue Brief No. 298, Employee Benefit Research Institute (EBRI), October 2006.

14. Brian Grow and Robert Berner, "Fresh Pain for the Uninsured: As Doctors and Hospitals Turn to GE, Citigroup, and Smaller Rivals to Finance Patient Care, the Sick Pay Much More," Business Week, November 21, 2007.

15. Cindy Zeldin and Mark Rukavina, "Borrowing to Stay Healthy: How Credit Card Debt Is Related to Medical Expenses," New York: Demos and The Access Project, January 2007.

16. Carol Pryor, Andrew Cohen, and Jeffrey Prottas, "The Illusion of Coverage: How Health Insurance Fails People When They Get Sick," Boston: The Access Project, 2007.

2. U.S. General Accounting Office, Canadian Health Insurance: Lessons for the United States (Washington, DC: June 1991); U.S. Congressional Budget Office, Estimates of Health Care Proposals from the 102nd Congress (Washington, DC: July 1993).

3. C. Schoen et al., "Why Not the Best: Results from a National Scorecard on Health System Performance," Commonwealth Fund Commission on a High Performance Health System, New York, September 2006.

10. American College of Physicians, Position Paper: "Achieving a High-Performance Health Care System with Universal Access: What the United States Can learn from Other Countries," Ann of Intern Med. 148 (2008):55-75.

Physicians for a National Health Programhttp://www.pnhp.org29 E. Madison, Suite 602Chicago, Il 60602Phone: (312) 782-6006Fax: (312) 782-6007PNHP's 15,000 members across the United States advocate for a universal, single-payer national health program. The Web site provides a wealth of information and resources. (You don't have to be an MD to join.)

All Unions Committee for Single Payer Health Care-HR 676http://unionsforsinglepayerhr676.orgc/o Nurses Professional Organization (NPO)1169 Eastern Parkway. Suite 2218Louisville, KY 40217Phone: (502) 636-1551A clearinghouse rather than an organization, this is where to find the names of the 400 local and international unions, state labor federations, and Central Labor Councils across the United States that have endorsed HR 676.

American Medical Student Association (AMSA)http://www.amsa.orgAMSA, with a half-century history of medical student activism, is the oldest and largest independent association of physicians-in-training in the United States, AMSA is a leading organization that works to rally students for national health care.

Healthcare-NOW!http://www.Healthcare.NOW.orgHealthcare-NOW! is a national campaign for a quality guaranteed nonprofit single-payer health care system in the United States.

Latinos for National Health Insurance (LNHI)http://www.latinos.nhi.orgLNHI is a national coalition working for equality in health care.LNHI's mission is to educate Latino organizations, individuals, government officials, and community leaders about the need to establish a comprehensive, universal, equitable, and affordable program of national health insurance in which everyone is covered from birth.

National Health Care for the Homeless Councilhttp://www.nhchc.orgThe National Health Care for the Homeless Council is a membership organization that works to improve access to health care, quality of care, and health status of homeless people as part of the broader struggle to end homelessness.

National Nurses Organizing Committee (NNOC)http://www.calnurses.org/nnoc/about.nnoc.htmlThe NNOC is a new national union and professional organization for Registered Nurses, Advance Practice Nurses, and RN organizations throughout the country who want to pursue a more powerful agenda-including getting national, guaranteed health care for life in the United States. One of the fastest-growing health care organizations in the United States, the NNOC presently has 80,000 members in 50 states.

SiCKOCure.orghttp://www.SiekoCure.orgSiCKOCure,org was set up for those who have seen the movie SiCKO and want to learn more about what they can do. It is a project of PNHP, California Nurses Association/NNOC, and HealthCare-NOW!

State and Local Organizations

California Nurses Association (CNA)http://www.calnurses.orgThe CNA, and its national arm, the NNOC (see above), is one of the nation's premier nurses' organizations and health care unions.

OneCareNow.org grassroots campaignhttp://www.onecarenow.orgOneCareNow is a 365-city program to educate millions of Californians and build massive support for passage of universal health care (SB 840) in California.

Single Payer Now!http://singlepayernow.netSingle Payer Now! is a grassroots association of volunteers supporting Universal Single Payer Healthcare for California since 1994.

Consumer Watchdogconsumerwatchdog.orgConsumer Watchdog is a California group that fights to protect patients, to improve the quality of health care, and to create universal health care.

Commonwealth Fundhttp://www.commonwealthfund.orgThe Commonwealth Fund is a private foundation that supports independent research on health care issues and offers grants to improve health care practice and policy.

Consumers Union (CU)http://www.consumersunion.orgCU is an expert. independent, nonprofit organization whose mission is to work for a fair. just, and safe marketplace for all consumers.

Demoshttp://www.demos.orgDemos is a nonpartisan public policy research and advocacy organization that focuses on four areas: democracy reform, expanding economic opportunity, restoring trust in a government by and for the people, and promoting new ideas in the public debate.

Families USAhttp://www.familiesusa.orgFamilies USA is a national nonprofit, nonpartisan organization working at the national, state, and community levels and dedicated to the achievement of high-quality, affordable health care for all Americans.

General Board of Church & Society (GBCs)http://www.umc-gbcs.orgGBCS is the international public policy and social justice agency of the United Methodist Church. GBCs advocates for health care for all in the United States by focusing on a single-payer national health plan on the state and federal levels, protecting the building blocks of universal health care (Medicare, Medicaid, Veterans Health, Indian Health Service, and employer-sponsored health care insurance), and promoting the Health Care Justice Sabbath Program.

Guaranteed Healthcarehttp://www.guaranteedhealthcare.orgGuaranteed Healthcare is an action page dedicated to getting the United States National Health Insurance Act passed. You can write your. representative, sign up for action alerts, communicate with the press, and tell your own story about the American medical system.

Health Affairshttp;//www.healthaffairs.orgHealth Affairs is the leading journal of health policy thought and research. Published since 1981, the journal is nonpartisan and presents a wide range of timely research and commentary on health issues of current concern in both domestic and international spheres. All articles Health Affairs has published are available online.

Kaiser Family Foundationhttp;//www.kff.orgA leader in health policy and communications, the Kaiser Family Foundation is a nonprofit, private operating foundation focusing on the major health care issues facing the United States. with a growing role in global health. Unlike grant-making foundations, Kaiser develops and runs its own research and communications programs. sometimes in partnership with other nonprofit research organizations or major media companies.

Medicare Rights Center (MRC)http://www.medicarerights.org/MRC is the largest independent source of health care information and assistance in the United States for people with Medicare. Founded in 1989, MRC helps older adults and people with disabilities get good, affordable health care.

Public Citizen Health Research Groupwww.citizen.orgPublic Citizen is a national, nonprofit consumer advocacy organization founded in 1971 to represent consumer interests in Congress, the executive branch, and the courts.

Olveen Carrasquillo, MD, MPH, is an Associate Professor of Medicine, Health Policy and Community Partnerships at Columbia University Medical Center. He is also the Director of the Columbia Center for the Health of Urban Minorities. His areas of research include minority health, health disparities, health insurance, and access to care.

Representative John Conyers Jr., a Detroit Democrat, was re-elected to the 14th Congressional District in November 2006, to his twenty-first term in the U.S. House of Representatives. For more than three decades, Congressman Conyers has led efforts in Congress to reform the health care system. He is the founder and chairman of the Congressional Universal Health Care Task Force.

Rose Ann DeMoro is the Executive Director of the California Nurses Association/National Nurses Organizing Committee, AFL-CIO, which, with 80,000 members, is the nation's largest union of direct care RNs. DeMoro has been honored by MSN as one of the most influential women of 2006, in Esquire's Best and Brightest issue, and as one of the 100 most influential persons in health care by Modern Healthcare for several years running.

Claudia M. Fegan, MD, is the Associate Chief Medical Officer for the Ambulatory and Community Health Network for the Cook County Bureau of Health Services and the former President of Physicians for a National Health Program. The daughter of a labor union organizer and a social worker, Fegan received her undergraduate degree from Fisk University and MD from the University of Illinois College of Medicine.

Oliver Fein, MD, is a practicing general internist, Professor of Clinical Medicine and Public Health. and Associate Dean at the Weill Cornell Medical College. He is Vice President of the American Public Health Association. Chair of the New York Metro Chapter of Physicians for a National Health Program (PNHP) and President. elect of National PNHP.

Leo W. Gerard is International President of the United Steelworkers and is the son of a nickel miner. As an eleven-year-old, he listened to union meetings held by his father in the basement of the family home. They instilled basic social democratic values and union principles and led to a lifelong commitment to social change and justice.

Marie Gottschalk, PhD, is a professor of political science at the University of Pennsylvania. A former journalist and editor, she is the author of. among other works. The Shadow Welfare State: Labor, Business. and the Politics of Health Care in the United States (Cornell, 2000) and The Prison and the Gallows: The Politics of Mass Incarceration in America (Cambridge, 2006).

Joanne Landy, MPH, MA, is the former executive director of the New York Metro Chapter of Physicians for a National Health Program. In addition to working on health care issues, Landy is co-director of the Campaign for Peace and Democracy.

Martha Livingston, PhD, is Associate Professor of Health and Society at the State University of New York College at Old Westbury. She is Vice-Chair of the Board of Directors of the New York Metro chapter of Physicians for a National Health Program.

Mary E. O'Brien, MD, is a primary care internist at Columbia University Health Services and a faculty member at the Columbia College of Physicians and Surgeons. She is on the Board of Directors of the New York Metro chapter of Physicians for a National Health Program and is the chair of its media committee.

Leonard Rodberg, PhD, is Professor and Chair of the Urban Studies Department at Queens College/CUNY, where he teaches health policy and other urban issues. He was one of the founders of Physicians for a National Health Program and now serves as Research Director of the NY Metro Chapter of PNHP.

Mark Rukavina is the Executive Director of the Access Project. which focuses on promoting health access at the local community level. He oversees all programs designed to assist communities in their efforts to address the health care access issue. He is responsible for developing strategies and community linkages with state and national health policy administrators.

Jaime Torres, DPM, MS, is the founder and president of Latinos for National Health Insurance, a national coalition of Latino leaders advocating for national health insurance. He is also an Associate at the Aesthetic Realism Foundation in New York and was on the Advisory Board of the National Hispanic Medical Association.

Nathan Wilkes is an entrepreneur and devoted father, currently living with his wife and three children outside Denver, Colorado. When not working, he often lectures on patient advocacy and emergency preparedness. Wilkes is currently on the boards of Health Care for All Colorado and the National Business Coalition for Health Care Reform.

James Winkler is the General Secretary of the General Board of Church and Society, the social justice and public policy advocacy agency of the eight-million-member United Methodist Church. The board is headquartered on Capitol Hill in Washington, DC in the historic United Methodist Building and works to secure health care for all people.

Cindy Zeldin is a health policy researcher with nearly a decade of public policy experience at the state and national levels. She is currently pursuing a PhD in Health Services Research and Health Policy at Emory University.

First and foremost, we would like to thank Ellen Adler for inviting us to write this book. We are tremendously grateful to her and to Jyothi Natarajan of The New Press both for the opportunity and for their generous help and advice.

Were it not for the twenty-year fight for a single-payer health program waged by Physicians for a National Health Program (PNHP), this volume would not have been written. We owe an enormous debt of gratitude to Oliver Fein, Joanne Landy, and Len Rodberg. In addition to their having contributed two of the chapters, they helped shape the book overall, identified potential contributors, and read and gave wonderful suggestions on much of the manuscript. Susan Moscou did a terrific edit of one of the chapters. Thanks to Steve Auerbach, Laura Boylan, Michelle Desanno, Debbie Feuerman, Elaine Fox, Ida Hellander, Robert Padgug, Carol Schneebaum, Betsy Todd, and Nick Unger for their guidance, research help, and suggestions. Thanks, too, to Stephen Kirkpatrick and the rest of the fabulous librarians at SUNY College at Old Westbury.

Many thanks to all of our contributors for their hard work and dedication to the movement for health care justice.

Martha would like to thank Roger Bellin, Carla Livingston, Samantha Livingston, Freddy Thomas, Jude Thomas, Ed Livingston, Chris Kennedy, Bill Livant, Diana Ralph, Anne Hunter, Suzanne Curley, Karen Palmer, and Freda Steinberger for their help, unfailing love, and support. Martha would like to honor the memory of Mila Rainof, who would have been a wonderful doctor.

Mary thanks John Gorman, a thoughtful reader and editor of every chapter, and her sons, Nick and Patrick, for their frank feedback on content and the design of the book from a younger generation's perspective. Finally, Mary thanks the thousands of patients she has treated over the past thirty years. It is they who compelled her to recognize that guaranteed and universal health care is indeed a human right.

Despite the best efforts of those we acknowledge above, the responsibility for any errors in the manuscript is ours alone.